tbuckley/cabot-search huggingface dataset:
CD14 Mouth ulcer mayhem secondary to dental fillings
Authors: Lokapriya Ananthan, Dorottya Godor, Natalie Stone
Journal: British Journal of Dermatology (2023)

Abstract Dental amalgam contains mercury, which may cause an uncommon lichenoid allergic contact dermatitis (ACD) affecting the oral mucosa in direct contact with the amalgam filling. Distinguishing a lichenoid amalgam reaction from oral lichen planus is challenging, both clinically and histopathologically. This case illustrates the important role that patch testing to dental materials can play in providing a simple answer in the management of resistant cases of mouth ulceration, protecting patients from exposure to potentially toxic immunosuppressive treatments. A 64-year-old woman presented with a 5-year history of oral ulceration affecting the buccal mucosa and tongue bilaterally. These ulcers were persistent, very painful and bled intermittently, causing a significant adverse effect on her quality of life. She worked as a manager at a local wildlife sanctuary, and hobbies included walking, writing and artwork. An incisional biopsy taken from an ulcer in the left buccal mucosa demonstrated a dense lichenoid inflammatory cell infiltrate. The oral surgical team treated her for presumed ulcerative oral lichen planus with multiple treatments, including topical steroids, high doses of oral prednisolone, hydroxychloroquine, mycophenolate mofetil and azathioprine. She gained only very minimal benefit. The oral surgeons then requested dermatological advice for the next potential treatment option, which was suggested to be rituximab. At this point, the surgeons noticed that the ulcers seemed to be most prominent at sites of the patient’s longstanding amalgam fillings and she was referred for patch testing. Patch tests were performed to the British Standard series, medicaments series and oral and dental series. Positive reactions were noted to both amalgam (D2+/D4+) and mercury (D2+/D4+). The patient had her amalgam fillings replaced with white acrylate fillings, and her oral ulceration completely healed without the need for any further immunosuppression. Clinically and histologically, lichenoid ACD secondary to dental fillings can be indistinguishable from idiopathic oral erosive lichen planus. However, the proximity of ulceration to dental filling materials should always raise the possibility of a lichenoid ACD and trigger referral for patch testing, preferably prior to systemic medications being tried. This case highlights the importance of patch testing in patients with localized, asymmetrical, difficult-to-treat oral ulcers adjacent to amalgam fillings, which could spare the patient from exposure to potentially harmful immunosuppressive treatments.
P83 Biologic and Janus kinase inhibitor therapy outcomes for severe psoriasis in trisomy 21
Authors: Cathal O’Connor, Berbie Byrne, Darren Roche, Garret O’Connell, Michael O’Connell, Michelle Murphy, John Bourke, Maeve Lynch, Mary Bennett
Journal: British Journal of Dermatology (2023)

Abstract Trisomy 21 (T21) is strongly associated with autoimmune disease, including psoriasis. Little is known about biologic outcomes for severe psoriasis in T21. T21-associated immune dysregulation has implications for efficacy, safety and drug survival of biologic medications. The aim was to review the outcomes of patients with T21 and severe psoriasis treated with biologic agents or Janus kinase inhibitors (JAKi) in our region. Patients were identified via databases of the regional dermatology departments in the province of Munster, Ireland. Information on demographics, comorbidities, previous and current therapies and response to therapies was retrospectively collated. Adequate treatment response was defined as a physician global assessment score of zero (indicating clear skin), or one (indicating almost clear skin). Twenty-one patients were identified (mean age 24.7 years). Most (76%) did not have a first-degree relative with psoriasis. One-third (33%) of patients had arthritis, but all children (n = 6) had arthritis. Ninety per cent (n = 18/20) of trials of tumour necrosis factor (TNF)-α inhibitors failed. Almost two-thirds (n = 7/11) of patients achieved adequate response with ustekinumab. All three patients treated with tofacitinib achieved adequate response following at least three biologic failures. The mean number of biologic/JAKi therapies received was 2.1, with an overall biologic/JAKi survival rate of 36%. Overall, 81% (n = 17/21) of patients required a switch from their index biologic treatment due to failure. The four patients who remained on their index biologic all received ustekinumab. In patients with T21 and severe psoriasis, failure of TNF-α inhibition is common, and ustekinumab therapy should be considered first line. There is an emerging role for JAKi.
PA19 A rare case of Buschke–Ollendorff syndrome
Authors: Kugili Sathanantham, Aysha Javed
Journal: British Journal of Dermatology (2023)

Abstract We present a case of Buschke–Ollendorff syndrome (BOS) in a 6-year-old girl. The BOS is rare genodermatosis distinguished by the presence of short stature and skeletal and connective tissue defects. This patient first attended the dermatology department with a history of small asymptomatic dermal papules and nodules noted overlying the skin on her abdomen since the age of 2 years. They became more numerous and evolved over her right buttock and left posterior calf. Subsequent investigation with ultrasound imaging illustrated that these lesions were elasotomas and, on a separate occasions, also suggested the possibility of a lipoma or collagenoma, and ruled out a sarcoma or malignancy. Skeletal survey of the upper limbs, hands, pelvis, lower limb and both feet highlighted the presence of well-defined sclerotic lesions involving the periarticular regions. This condition was again confirmed by clinical geneticists who advised that future family planning and confirmatory testing would identify the presence of LEMD3, responsible for this autosomal dominant condition. There was no history of genetic disorder within the family, but it was noted that the patients and both parents had a short stature, which is another hallmark feature of this condition. On successive reviews, the patient continued to display gradual enlargement of her elastomas and developed other cutaneous manifestations, including congenital naevi. This case report contributes to the appreciation of the clinical manifestation of this uncommon condition.
DE01 Swabs: a practical way to teach medical students about cutaneous infections
Authors: Avad Mughal
Journal: British Journal of Dermatology (2023)

Abstract It is well established that dermatology is poorly understood among medical students and doctors of all grades. The combination of time allocated to teaching of dermatology, as well as the high impact of the hidden curriculum reinforcing dermatology as difficult and mysterious, lends itself to perpetuation of the zeitgeist. Cutaneous infections have a particularly high cognitive load due to their relatively short presentation time and wide varieties of manifestations. Investigation of cutaneous infections is also problematic with incorrect sampling undertaken for different infections. Junior doctors frequently default to black charcoal swabs for all skin infections, often getting feedback as inappropriate investigation after the patient has been discharged or are being read by different doctors altogether due to shift working. For 8 years, we have been running a practical tutorial session on skin infections at Swansea University Medical School. Old venesection prosthetic arms are decorated with simulation bacterial, fungal and viral infections. The bacterial pus is cold custard (or ‘pustard’) on swollen reddened sections. Herpetic vesicles are simulated with bubble wrap injected with Hibiscrub®. Tinea is simulated by dry polyvinyl acetate glue surrounded by red marker. The students have access to black charcoal swabs, red viral swabs, scalpels and fungal scraping cards. They also have dry universal containers and investigation forms. The 10–12 year-2 students are tasked with diagnosing each infective presentation with a short history and medical photography to back up the prosthetic representation. They then have to select the most appropriate investigative method and information to give to the microbiology department. Some students only have access to black charcoal swabs and need to improvise working out how to use the universal containers for their investigations. The knowledge is then shared at the end of the 40-min tutorial. This is conducted a day before the skin infection lecture, to reduce the cognitive load of that lecture. There has been consistently good feedback for this session, which allows students to think in real time about common clinical scenarios, making best use of laboratory services and improvising investigative techniques, where appropriate resources may not be available. The prosthetics have worked well year on year. Many of our first students are now practising doctors locally, and their dermatology knowledge is manifest in referrals. By practising the techniques in simulation, they are comfortable doing so in working life.
DE03 Using the British Association of Dermatologists’ medical student app to promote a better representation of skin of colour in undergraduate education
Authors: Chirag Patel, Daryl Teo, Matthew Scorer, Ingrid Helbling
Journal: British Journal of Dermatology (2023)

Abstract It was exactly 10 years ago, in Liverpool, that the ‘BAD medical student app’ was launched. At a time when digital learning was becoming popular, a platform that is accessible globally, on your phone, which provides evidenced-based information to aid medical students’ educational needs in undergraduate dermatology, was born. In the wake of the need for promoting fair medical education, the General Medical Council, in their ‘2021–25 corporate strategy’, stipulated a requirement for an increased focus on equality, diversity and inclusion in medical education. Furthermore, medical students lack training on how skin disease presents differently in patients who have darker skin tones (Adelekun A. Skin color in dermatology textbooks: an updated evaluation and analysis. J Am Acad Dermatol 2021; 84:194–6). A 2018 study of general medicine texts found that &amp;lt; 5% of images included dark skin tones. Louie and Wilkes (Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Soc Sci Med 2018; 202:38–42) discovered that in general medicine texts commonly used by medical students, &amp;lt; 5% of the images included darker skin tones. The effects of the COVID-19 pandemic and the semipermanent transition to using virtual learning methods have required medical students to become more autonomous in supplementing what is learnt in lectures. Furthermore, the under-representation of skin of colour in primary medical texts will lead to students connecting diagnosis with a one-dimensional presentation and, in turn, hesitation in diagnosing skin diseases in darker skin tones. Understanding the existence of this limitation and recognizing the value of using the British Association of Dermatologists’ medical student app to reach out to medical students, we embarked upon a project to diversify education on cutaneous diseases in darker skin tones. The app, which contains didactic clinical information, as well as picture quizzes designed to challenge a student’s ability to make a spot diagnosis, has been expanded to include a larger proportion of images of darker skin tones. Where cutaneous diseases present significantly differently in lighter and darker skin tones, we have included contrasting images to illustrate this. We hope these structural changes to the app will complement higher initiatives to improve equity in skin-of-colour image representation in undergraduate medical education on cutaneous diseases.
001 Does atopic dermatitis in childhood impact later educational attainment? A UK birth cohort study
Authors: Rita Iskandar, Sigrún Schmidt, Amy Mulick, Katrina Abuabara, Sinéad Langan
Journal: British Journal of Dermatology (2023)

Abstract Atopic dermatitis (AD) may impair educational attainment in numerous ways, including poor attention due to itching and disrupted sleep quality. Educational attainment is a social determinant of health; thus, any association with AD, a prevalent chronic disease, is important to understand. We aimed to determine whether AD is associated with lower educational attainment using data collected between 1990 and 2009 on children enrolled in the Avon Longitudinal Study of Parents and Children (ALSPAC) and linked to the National Pupil Database. Participants were 13,956 children alive at 1 year of age and followed up with repeated measures of AD until 11.5 years of age. The outcome was educational attainment, defined as achieving at least five General Certificates of Secondary Education (GCSEs) at grades A*–C by 16 years of age. Using multivariable logistic regression, we assessed the effect of AD on educational attainment, adjusting for potential confounders. We included 7577 children in a complete record analysis: 3258 (43.0%) with evidence of AD (two positive AD reports) and 4319 (57.0%) without AD reports (comparator group). Compared with children without AD, children with AD had 30% increased odds of attaining ≥ 5 A*–C GCSEs [adjusted odds ratio (aOR) 1.30, 95% confidence interval (CI) 1.17–1.45]. Children with AD had a 9.9% absolute excess probability of achieving ≥ 5 A*–C GCSEs vs. children without AD. In a stratified analysis, asthma was shown to enhance the strength of the association of AD with educational attainment [probability in AD vs. no AD groups: 62.7% vs. 47.3%; aOR 1.58, 95% CI 1.19–2.10 (P = 0.04 for interaction)]. AD appeared to be associated with higher educational attainment in English children. Despite the magnitude and strength of the findings, cautious interpretation is required due to the dichotomous outcome measure, poor generalizability and potential unmeasured confounding. Further investigations should evaluate reproducibility in other populations, stratify by AD trajectory–severity phenotypes and use quantitative test scores.
BI29 Crusted scabies: a complicated course in a renal transplant recipient
Authors: Eimear Duff, Daniel Lyons, Karen Eustace, Sinead Collins
Journal: British Journal of Dermatology (2023)

Abstract A 55-year-old man of Nigerian origin was admitted with a 3-month history of a generalized rash that was intensely pruritic at night. He had received a renal transplant 1 year prior for end-stage kidney disease in the context of hypertensive nephropathy. His maintenance immunosuppressive regimen includes mycophenolate mofetil, tacrolimus and prednisolone. No household contacts were affected by itch. He had been treated with the topical scabicide permethrin cream in the community, resulting in a painful fissuring of the lower limbs that prompted presentation to the emergency department. Full skin examination revealed an extensive scaling eruption, with profuse skin shedding and lichenified fissuring of the lower limbs. There were also loosely adherent, grey, hyperkeratotic scaling plaques widely extending from the genitals to mid-thigh and posterior upper limbs, with involvement of the ear lobes. There was relative sparing of the acral areas. He was initially treated empirically with oral ivermectin, oral flucloxacillin and topical clobetasol propionate ointment and paraffin gel. A full blood count revealed a prominent eosinophilia. A punch biopsy later revealed a number of scabies mites. He was prescribed ivermectin as per the Centers for Disease Control guidelines for crusted scabies in immunosuppressed populations with oral ivermectin 200 μg kg–1 on days 1, 2, 8, 9, 15, 22 and 29. Supply issues in the community delayed his treatment course. Further topical antiscabietic therapy was deferred until tolerated. He was subsequently re-admitted with methicillin-sensitive Staphylococcus aureus bacteraemia with pyelonephritis of the transplant kidney. The prescribed treatment regime of oral ivermectin, a topical keratolytic cream and topical permethrin cream daily for 7 days was completed as an inpatient. This yielded complete resolution of his crusted lesions. He responded well to a prolonged course of intravenous flucloxacillin. This case illustrates the challenge of diagnosing scabies in richly pigmented skin, as well in the immunosuppressed host (in this case due to defective T-cell responses). Maintaining a high index of suspicion is essential in the context of unexplained itch in the immunosuppressed as they may present with atypical presentations. Such vigilance will improve the recognition and management of this uncommon, potentially life-threatening infectious complication of crusted scabies in the transplant population (Wang MK, Chin-Yee B, Lo CKL et al. Crusted scabies in a renal transplant recipient treated with daily ivermectin: a case report and literature review. Transpl Infect Dis 2019; 21:e13077).
P53 Incidence of merkel cell carcinoma in the Republic of Ireland (1994–2019)
Authors: Claire Doyle, Marta Costa Blasco, Orla McFeeley, Paula Beatty, Sarah O’Mahoney, Lisa Murphy, Madonna Andrawis, Anne Marie Tobin
Journal: British Journal of Dermatology (2023)

Abstract Merkel cell carcinoma (MCC) is a rare, aggressive, neuroendocrine cutaneous malignancy most commonly observed in those aged over 65 years. MCC is twice as common in males as in females and is 25 times more common in those with fair skin than in those with darker skin types. Solid organ transplant recipients have a 24-fold increased risk of developing MCC. There has been a 95% increase in the incidence of MCC in the USA from 2000 to 2013, with further increases predicted. The aim of this study was to investigate the trends of incidence of MCC in the Republic of Ireland. Age-standardized rates were calculated using the 2013 European standard population. There were 447 histologically confirmed MCCs diagnosed between 1994 and 2019. Forty-nine per cent of cases (n = 220) were in males. Median age was 80 years (range 15–19 to 95+). The median age for males was 78 years and the median age for females was 82 years. On average, there were seven cases of MCC diagnosed annually between 1994 and 1998 vs. 27 cases of MCC annually diagnosed between 2015 and 2019—almost a quadrupling of case numbers. The age-adjusted incidence rate of MCC for both male and females is detailed in Table 1. Previous literature has indicated that MCC is twice as common in males than in females. Our cohort differed in that there was a slight female predominance in patients diagnosed with MCC. This is in keeping with published literature from Northern European groups, which have also demonstrated a female predominance in MCC. While the absolute number of MCC diagnosed in Ireland has increased in both males and females, the age-adjusted incidence rate is increasing in males, but there has not been a significant change in females. Other Northern European groups have also demonstrated an increase in the incidence of MCC in males that was not observed in females. This study adds to the body of epidemiological data on MCC.Table 1Age-adjusted incidence rates of Merkel cell carcinoma (MCC)Cases of MCCAge-standardized rate (per 100 000 person years)SE95% confidence intervalMales1994–1999230.520.130.27–0.772000–2004210.370.080.21–0.532005–2009350.790.150.50–1.082010–2014661.190.160.88–1.502015–2019751.050.120.81–1.29Females1994–1999260.360.070.22–0.502000–2004440.670.100.47–0.872005–2009540.790.110.57–1.012010–2014450.570.090.39–0.752015–2019580.650.090.47–0.83
DE02 Honing in on clinician needs: a grassroots development of an educational resource for dermatologists
Authors: Rachel Blyth, Zainab Jiyad, Leila Ferguson, Vanessa Pinder
Journal: British Journal of Dermatology (2023)

Abstract Keeping up with the influx of scientific research papers can feel overwhelming, especially alongside busy clinical responsibilities. A PubMed search of the term ‘dermatology’ produced 29 565 results for 2021 alone, and, consequently, clinicians face spending hours a week scanning journals just to stay up to date. This is coupled with increasing clinical demand due to rising waiting lists and skin cancer pressures. Innovative solutions to the problem include regular newsletters, which have been proven to be an effective tool in medical education in other specialities (Kolli A, Nguyen A, Portney D et al. The Lens: can a weekly newsletter improve medical student knowledge of the ophthalmology literature? J Surg Educ 2021; 78:1905–14). To address this challenge in dermatology, we created a newsletter to make dermatology research more accessible. Two consultant dermatologists created a system whereby clinically relevant articles are chosen following a review of ∼30 journals. These are condensed into short clinical summaries, containing relevant findings, limitations and applicability, emulating a journal club style. This was initially distributed within our local hospital, but the team and readership have since expanded. From January 2022, in addition to the written newsletter, a freely available podcast for each newsletter was created giving an opportunity to learn on the move (e.g. while commuting). At 12 months, the newsletter has 206 subscribers, and the podcast has achieved 810 total plays (with download locations ranging from the USA to India). More recently, we have reached new audiences via Instagram, with 1700 views and 123 likes of the content thus far. A survey was distributed to current subscribers to determine the usefulness of the newsletter as an educational resource. Eighteen responses were received, and 100% agreed that they felt more informed on recent publications in dermatology from reading the newsletter (83% strongly agreed; 17% agreed). In addition to this, 100% felt that the articles chosen were relevant to their clinical practice (78% strongly agreed; 22% agreed). Feedback included comments such as ‘it is a great way to keep informed on recent publications that may be of interest’ and ‘super useful bite-sized information’. The General Medical Council guidance on Good Medical Practice requires doctors to ‘keep professional knowledge and skills up to date’. We feel the interest in our grassroots journal club publication and the survey results (with all our respondents feeling more informed on dermatological research, particularly with articles relevant to their clinical practice) highlight an unmet need for accessible educational resources to enable busy dermatologists to become aware rapidly and efficiently of the latest clinical developments.